Abraham S. Abraham, M.D., F.R.C.P.
Director, Internal Medicine B, Shaare Zedek Medical Center, Jerusalem

The following excerpt is taken from the author's Halachot for the Physician on the Sabbath and Festivals. pp. 17-28
ASSAI - Vol IV, No 1 February 2001

Blood Taking
28. It is permissible to withdraw blood - venous, arterial, or capillary - only from a seriously or possibly seriously ill patient. This is true even if the results would not be available until after the Sabbath, if this is necessary for diagnosis or treatment. However, where possible blood should be drawn from one source and not from both artery and vein.1 Additional blood for routine purposes may not be drawn unless as part of the same act. Thus, when using a vacutainer the tube may be allowed to fill even though not all the blood is urgently required and the rest would be used (after the Sabbath) for routine tests. However, when blood is withdrawn using a syringe, only the amount of urgently required blood may be taken.2

29. A glucometer may be used for a seriously ill diabetic patient or for a patient on multiple insulin injections (according to blood sugar levels). It should be switched on, where possible, by a gentile or in an indirect manner (dorsum of a finger or hand).3

30. When blood, etc., are sent to the laboratory, a gentile should be asked to write the necessary details; otherwise, the physician should write only what is absolutely necessary, using the left hand (if he is right-handed).

31. When laboratory results are received for a number of patients at the same time, they may not be sorted out according to patient. Instead, each must be looked at and then filed in the appropriate chart.4

Fluid Tap
32. Ascites, pleural effusion, or fluid in a joint may be tapped on the Sabbath for diagnosis or treatment.5 A patient with neurological signs may of course have a spinal tap performed if considered necessary. An abscess associated with systemic symptoms such as fever may be tapped or surgically drained.6

Urinalysis
33. The urine of a patient who is possibly seriously ill may be examined using dipsticks, preferably by allowing the urine to flow onto the dipstick rather than by dipping the stick into the urine.7

Injections and IV Infusions
34. It is permissible to tear the wrapping off a syringe, medication, or IV fluid container, including tearing through a perforation. If possible, one should tear between letters or words8 and not through the print.9

35. A non-seriously ill patient may be treated with subcutaneous or intramuscular injections on the Sabbath.10 However, one should not swab with cotton wool or gauze soaked in alcohol, even if held with forceps and even if soaked before the Sabbath. One should preferably use nylon (nonabsorbent) swabs if available, or, if not, alcohol or iodine should be poured on to the appropriate part of the body and then wiped off with absorbent cotton wool or gauze.11 A syringe with a pre-attached needle should preferably be used; if there is real need, the appropriate needle may be attached to a syringe for use.12

36. Intravenous injections may only be given to a seriously ill or possibly seriously ill patient.13 Similarly one may not insert an IV line just to have an open vein in case of emergency unless such an emergency is an expected possibility. However, if a vein is already cannulated, IV fluids and injections may be given, even to a non-seriously ill patient.

37. A seriously ill patient with severe pain may be given intravenous morphine or other narcotics since whatever may reduce suffering or calm such a patient is part of the duty to save life.14

Wounds
38. A superficial wound should be cleaned using nylon (nonabsorbent) swabs, or else by iodine, etc., poured onto the wound and then wiped off with a dry swab or gauze. If, however, there is a suspicion that the wound is infected it should be cleaned in the usual way (if nonabsorbent swabs are not available).15

39. One may bandage a wound - or change the bandage - on the Sabbath without using an ointment (unless as described in paragraph 41).16 The bandage should be secured with a single knot and bow, safety pins, or special clips, but adhesive tape should not be used for this purpose.17 A bandage should not be cut to length, nor should it be split lengthwise in order to tie the ends together.18

40. One may apply a Band-Aid on the Sabbath, but the protective paper covering the two adhesive tabs should preferably be removed before the Sabbath. Failing this, it may, if necessary, be removed on the Sabbath.19 If this was done and the protective paper immediately replaced before the Sabbath, it may be removed again before use on the Sabbath.20

41. One may press ointment from a tube directly onto a wound or apply it with a spatula if the wound is infected or painful. A gauze or bandage may then be put on the wound even if it would then automatically be spread. However, one must be careful not to actively spread the ointment onto the wound.21

42. A non-seriously ill patient for whom treatment involving rabbinically prohibited acts is permitted must have everything done for him as necessary, even if only for cosmetic reasons, provided that no Torah prohibitions are set aside.22 Thus one is permitted to ask a gentile physician to stitch a cut on the face which, if merely covered with elastoplast, might result in a scar.

If, however, he is seriously ill, such as a patient with a severed limb, one may attempt to rejoin the amputated limb even though this would involve many more Torah prohibitions than would merely closing the stump.23 Similarly, when stitching a life-threatening wound, one may add more stitches than strictly necessary, if only in order to obtain a good cosmetic result.24

43. A bedridden patient who may develop pressure sores if not treated prophylactically, and certainly one who already has such sores, is a seriously ill patient and should be treated with cream or, if necessary, even ointment.25

44. A bedridden patient who has or who may develop pressure sores may be put on an air mattress which has to be electrically activated on the Sabbath.26

Suturing
45. The juxtaposition of the two ends of a wound by suturing may only be done if the patient is or may become seriously ill as a result of the wound.27 However, it is, under all circumstances, permissible to do so using a butterfly dressing, plaster (that has been pre-cut, before the Sabbath), or special glue.28

46. Cotton wool may be used to pack the open cavity of a patient who has died during laparotomy or thoracotomy, in order to absorb the blood and retain the contents while the deceased is being transferred to the hospital morgue.29 A gentile, if available, should be asked to stitch the wound together.30 If not, the surgeon may close the wound, stitching with his left hand.31

Pacemaker
47. A seriously ill patient or even one who only may be so may have a pacemaker inserted as on a weekday under fluoroscopic control. However, a temporary pacemaker that is functioning satisfactorily should not be changed for a permanent one on the Sabbath.

48. A patient with a temporary pacemaker may have it removed on the Sabbath or the weaning process started even if it is actually removed only after the Sabbath.

Weaning off a Respirator
49. A respirator patient may have the weaning process started on the Sabbath even if the disconnection takes place only after the Sabbath.

Fractures
50. A patient with a serious fracture (that is or may be a danger to life) may be X-rayed on the Sabbath and treated as necessary.

51. A fracture or dislocation may be stabilized, using an improvised splint such as a board or stick, before the patient is taken to hospital.

52. A dislocation may be reset since it may cause danger to the limb. If anesthesia is necessary for the procedure, only rabbinically prohibited acts are permitted by a Jew but a gentile can be asked to do even Torah-prohibited acts. If there is any question of danger to life, however, everything necessary to ward off this danger is permissible.32

53. A fracture that is not life threatening may be bandaged33 but not put into a plaster cast.34 However, a gentile may be asked to do so.35 If, however, there is any doubt that the fracture may be life threatening, the patient must be treated as on a weekday.36

54. A plaster cast that is causing severe pain or vascular insufficiency may be removed or cut if there is any doubt that leaving it as is may lead to a life-threatening situation. The saw itself should, if possible, be switched on by a gentile or in an indirect manner (dorsum of hand or back of finger).37

COMMENTS:

1. Shemirat Shabbat ke-Hilkhata 30:27.
2. Heard from R. Yehoshua Y. Neuwirth.
3. Heard from R. Shlomo Zalman Auerbach and R. Neuwirth.
4. Shemirat Shabbat ke-Hilkhata 30:35, but see responsa Tsits Eli'ezer 12:35 where it is permitted. See also Lev Avraham, pt. 1, p. 25.
5. In principle, it is also permitted for a non-critically ill patient because the liquid is stored up (mifqad paqid)-heard from R. Neuwirth.
6. Shemirat Shabbat ke-Hilkhata 35:16. See also Nishmat Avraham, vol. 1 (Orah Hayyim), 328, notes 64, 65 (p. 204), and p. 349 in the name of R. Auerbach.
7. R. Auerbach in Shemirat Shabbat ke-Hilkhata 33, footnote 83.
8. Shemirat Shabbat ke-Hilkhata 9, footnote 48.
9. Ibid., 33:4 and 9:4.
10. Ibid., 33:7.
11. Ibid., 33:10.
12. See what R. Auerbach wrote, ibid., vol. 3, 35, footnote 63; and thus I heard from him. See also Nishmat Avraham, vol. 5 (Orah Hayyim), 313, note 1, and pp. 355-64. See also responsa Or le-Tsiyyon, pt. 2, 46:19, where it is forbidden.
13. Shemirat Shabbat ke-Hilkhata 32:58. See also Nishmat Avraham, vol. 1 (Orah Hayyim), 320, note 1 (p. 158).
14. Heard from R. Auerbach. See also Shemirat Shabbat ke-Hilkhata 32, footnote 105.
15. Shemirat Shabbat ke-Hilkhata 35:2.
16. Ibid.
17. Ibid., 35:22-25.
18. Ibid., 35:21.
19. Heard from R. Auerbach.
20. Shemirat Shabbat ke-Hilkhata 35:36. See also Nishmat Avraham, vol. 1 (Orah Hayyim), 328, end of note 62, and in notes 545 and 546 (p. 204). See also responsa Or le-Tsiyyon, pt. 2, 56:15, where it is permitted a priori.
21. Shemirat Shabbat ke-Hilkhata 33:14.
22. R. Auerbach, ibid., note 23.
23. R. Auerbach in Nishmat Avraham, vol. 2 (Yoreh De'ah), 369, end of note 2 (p. 270).
24. R. Auerbach, ibid. vol. 4 (Orah Hayyim), 340, note 2 (p. 62).
25. Even if he is not in danger at the moment, since spreading the ointment until it is entirely melted and absorbed into the person's body is not considered smearing (memareah), it is not forbidden unless the ointment remains unabsorbed and he wants to smooth it on his body (R. Auerbach in Shemirat Shabbat ke-Hilkhata 33, middle of note 58).
26. Heard from R. Neuwirth.
27. R. Auerbach and R. Shalom Y. Eliashiv in Nishmat Avraham, vol. 4 (Orah Hayyim), 340, note 12 (pp. 60-62).
28. R. Auerbach, ibid., vol. 5 (Orah Hayyim), 340, note 2.
29. Heard from R. Auerbach.
30. Heard from R. Neuwirth. See also Nishmat Avraham, vol. 4 (Orah Hayyim), 340, end of note 2 (p. 63).
31. "Because human dignity is so important" (ki gadol kevod ha-briyot)- heard from R. Auerbach. See also Nishmat Avraham, vol. 5 (Orah Hayyim), 340, note 3.
32. Shemirat Shabbat ke-Hilkhata 33:17; Nishmat Avraham, vol. 1 (Orah Hayyim), 328, note 68 (p. 205).
33. Shemirat Shabbat ke-Hilkhata 33:18.
34. Ibid. 33:3.
35. Ibid. 38:7.
36. Ibid. 35:5.
37. Heard from R. Neuwirth.

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